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1.  Acceptability of Pre-Exposure Prophylaxis (PrEP) as an HIV prevention strategy: Barriers and facilitators to PrEP uptake among at-risk Peruvian populations 
This study examined Pre-Exposure Prophylaxis (PrEP) acceptability among female sex workers, male-to-female transgendered persons, and men who have sex with men in Lima, Peru. Focus groups explored social issues associated with PrEP acceptability and conjoint analysis assessed preferences among eight hypothetical PrEP scenarios with varying attribute profiles and their relative impact on acceptability. Conjoint analysis revealed that PrEP acceptability ranged from 19.8 to 82.5 out of a possible score of 100 across the eight hypothetical PrEP scenarios. Out-of-pocket cost had the greatest impact on PrEP acceptability (25.2, p <0.001), followed by efficacy (21.4, p <0.001) and potential side effects (14.7, p <0.001). Focus group data supported these findings, and also revealed that potential sexual risk disinhibition, stigma and discrimination associated with PrEP use, and mistrust of health care professionals were also concerns. These issues will require careful attention when planning for PrEP roll-out if proven efficacious in ongoing clinical trials.
doi:10.1258/ijsa.2009.009255
PMCID: PMC3096991  PMID: 21571973
South America; HIV; MSM; FSW; PrEP Acceptability
3.  Preference for physician vs. nurse initiated opt-out screening on HIV test acceptance 
AIDS care  2013;25(11):10.1080/09540121.2013.772283.
Provider initiated opt-out HIV screening suggests that providers should routinely order HIV tests unless a patient declines. However, data on how providers will respond to this new screening model is scarce. Documented concerns from the providers’ perspectives have included time constraints of a typical patient encounter, and discomfort with discussing sexual history and risk behavior with patients. To address these potential barriers, nurse-initiated screening has been proposed as an approach to increasing screening rates in general medical and urgent care settings. This study compares patient acceptability of provider-initiated opt-out HIV screening with nurse-initiated opt-out HIV screening among 220 patients between the ages of 18–64 from two publically funded “safety-net” outpatient clinics in Los Angeles County. Our study found that 77% of patients agreed to HIV testing using opt-out screening, and that HIV test acceptance was higher with the physician initiated opt-out model compared with the nurse initiated opt-out model (Adjusted odds ratios[AOR]=2.92; 95% CI=1.37–6.22). These findings indicate that adding opt-out screening to primary care providers responsibilities may be an acceptable and effective strategy for addressing the perennially low HIV testing rates, particularly among low income, traditionally underserved patient populations among whom the epidemic is expanding most rapidly.
doi:10.1080/09540121.2013.772283
PMCID: PMC3679256  PMID: 23425325
HIV/AIDS; Opt-out screening; test acceptance; health care providers
4.  The role of mental health in mediating the relationship between social support and optimal ART adherence 
AIDS care  2013;25(9):1179-1184.
Optimal adherence to antiretroviral therapy (ART) is essential for reducing mortality and morbidity in persons living with HIV/AIDS (PLWHA), as well as for reducing the risk of further HIV transmission. While studies have identified psychosocial factors such as lack of social support and poor mental health status as important barriers to optimal ART adherence, few studies have explored the potential of a mediation effect of psychosocial factors on the relationship between social support and optimal ART adherence. This paper assessed whether mental health status mediated the relationship between social support and optimal ART adherence among a cross sectional sample of 202 persons living with HIV who were recruited from HIV clinical care sites and community-based organizations in Los Angeles County. Participants completed a survey that included social support items from the Medical Outcome Study: Social Support Survey (MOS-SSS) Instrument, mental health measures from the Medical Outcomes Study Short Form (SF-12), and ART adherence based on self-report. Among those currently taking ART, 61.7 percent reported having optimal adherence. Social support was significantly associated with high score on the mental health status scale (AOR = 2.90; 95% CI = 1.14-5.78) and optimal ART adherence (AOR = 1.81; 95% CI = 1.81; 95% CI = 1.18-2.79). When mental health status was introduced into the model, the association between social support and optimal ART adherence was no longer significant. Our findings suggest the HIV interventions targeting social support to improve ART adherence will likely be most successful if the support bolsters the mental health of the participants. Clearly, better understanding the relationships among social support, mental health, and ART adherence will be critical for development and implementation of future ART adherence interventions.
doi:10.1080/09540121.2012.752787
PMCID: PMC3633692  PMID: 23320407
HIV/AIDS; ART adherence; social support; mental health; mediation analyses
5.  Rectal Douching and Implications for Rectal Microbicides among Populations Vulnerable to HIV in South America: A Qualitative Study 
Objective
While gel-formulated Rectal Microbicides (RM) are the first to enter clinical trials, rectal douching in preparation for anal intercourse is a common practise, thus RMs formulated as douches may be a convenient alternative to gels. Nonetheless, little is known about potential users’ thoughts regarding douche-formulated RMs or rectal douching practises, data needed to inform the advancement of douche-based RMs. This qualitative study examined thoughts regarding douches, their use as a RM and current douching practises among men who have sex with men and transgender women.
Methods
Ten focus groups and 36 in-depth interviews were conducted (N=140) to examine the overall acceptability of RM, of which one component focused on rectal douching. Focus groups and interviews were recorded, transcribed verbatim and coded; text relating to rectal douching was extracted and analysed. Sociodemographic information was collected using a self-administered questionnaire.
Results
Support for a douche-formulated RM centred on the possibility of combined pre-coital hygiene and HIV protection, and it was believed that a deeply-penetrating liquid douche would confer greater HIV protection than a gel. Drawbacks included rectal dryness; impracticality and portability issues; and, potential side effects. Non-commercial douching apparatus use was common and liquids used included detergents, vinegar, bleach, lemon juice and alcohol.
Conclusions
A douche-formulated RM while desirable and perceived as more effective than a gel-formulated RM also generated questions regarding practicality and side-effects. Of immediate concern were the non-commercial liquids already being used which likely damage rectal epithelia, potentially increasing HIV infection risk. Pre-coital rectal douching is common and a RM formulated as such is desirable, but education on rectal douching practices is needed now.
doi:10.1136/sextrans-2013-051154
PMCID: PMC4035233  PMID: 23966338
rectal douching; microbicides; HIV prevention; MSM; transgender women; South America
6.  Understanding STI Risk and Condom Use Patterns by Partner Type Among Female Sex Workers in Peru 
The Open AIDS Journal  2014;8:17-20.
While brothel-based sex work is regulated by the Peruvian government, there is little data on STI risk factors reported by female sex workers (FSW). This study compared high risk behaviors among 120 Peruvian FSW from government regulated brothels with both clients and non-commercial partners. Our study found that 12% of FSW reported unprotected vaginal sex with clients (compared to 75% with non-commercial partners), and 42% reported unprotected anal sex with clients (compared to 87% with non-commercial partners). Group differences were observed in the expectation to have oral sex (32% for partners vs 60% for clients; p<0.01), and a history of anal sex (65% for partners vs 32% for clients; p<0.01) and both vaginal and anal sex with the same partners (46% for partners vs 25% for clients; p<0.001). These findings suggest that FSW constitute an important bridge population for STI/HIV transmission in Peru.
doi:10.2174/1874613601408010017
PMCID: PMC4062928  PMID: 24949112
Bridge population; condom use patterns; female sex workers; Peru; STI risk and transmission.
7.  An Elective Course to Engage Student Pharmacists in Elementary School Science Education 
Objective. To develop and assess the impact of an elective course (HealthWISE) on student pharmacists’ skills in communication and health promotion and elementary school students’ knowledge of and attitudes toward science.
Design. Three colleges and schools of pharmacy collaborated to develop a 1-credit elective course that used online and classroom teaching and learning techniques to prepare student pharmacists to teach science in elementary school classrooms. Student pharmacists delivered 6 science lessons to elementary students over the course of 2 months.
Assessment. In weekly journal reflections and a final paper, student pharmacists reported improved communication and health promotion skills. Elementary teachers reported they were satisfied with student pharmacists’ performance in the classroom. On pretest and posttest evaluations, elementary students demonstrated increased science knowledge and enhanced enthusiasm for science following the lessons taught by student pharmacists.
Conclusions. The HealthWISE elective course provided positive benefit for student pharmacists, elementary school teachers, and elementary students.
doi:10.5688/ajpe7510203
PMCID: PMC3279034  PMID: 22345722
service-learning; communication skills; health promotion; STEM education
8.  The Impact of Acculturation on Utilization of HIV Prevention Services and Access to Care Among an at-Risk Hispanic Population 
Introduction
HIV/AIDS disproportionately affects Hispanics in the United States, a diverse and heterogeneous population. The purpose of this study was to evaluate the relationship of acculturation with HIV and hepatitis C testing, and access to care among Hispanics at risk for HIV.
Methods
We recruited 600 Hispanics from STD clinics, community-based organizations, and needle exchange programs in Los Angeles County.
Results
Low levels of acculturation were significantly associated with having fewer HIV tests (OR = 1.98; 95% CI = 1.24, 3.15), no hepatitis C tests (OR = 2.61; 95% CI = 1.77, 3.84), testing positive for HIV (OR = 2.67; 95% CI = 1.04, 6.83), and low levels of access to care (β = 0.06; p<.05).
Conclusions
Low levels of acculturation are an important barrier to the use of HIV-related health care services. Our findings may inform the development of effective interventions that address the cultural and behavioral differences among Hispanic subgroups.
doi:10.1353/hpu.0.0204
PMCID: PMC2874820  PMID: 20168013
Acculturation; HIV; hepatitis C; access to care
9.  The Association of Stigma with Self-Reported Access to Medical Care and Antiretroviral Therapy Adherence in Persons Living with HIV/AIDS 
Journal of General Internal Medicine  2009;24(10):1101-1108.
Background
The stigma of HIV-infection may profoundly affect the lives of persons living with HIV/AIDS (PLHA). However few studies have examined the association of HIV stigma with multiple components of HIV treatment and care.
Objectives
To estimate the association between HIV stigma and: self-reported access to care, regular source of HIV care, and antiretroviral therapy adherence; and to test whether mental health mediates these associations.
Design
Cross-sectional study.
Participants
202 PLHA living in Los Angeles County in 2007.
Measurements
Participants completed an anonymous survey, assessing internalized HIV stigma (28-items, alpha = 0.93), self-reported access to medical care (six items, alpha = 0.75), regular source of HIV care, and antiretroviral therapy (ART) adherence.
Results
One-third of participants reported high levels of stigma; 77% reported poor access to care; 42.5% reported suboptimal ART adherence; and 10.5% reported no regular source of HIV care. In unadjusted analysis, those reporting a high level of stigma were more likely to report poor access to care (OR = 4.97, 95% CI 2.54–9.72), regular source of HIV care (OR = 2.48, 95% CI 1.00–6.19), and ART adherence (OR = 2.45, 95% CI 1.23–4.91). In adjusted analyses, stigma was significantly associated with poor access to care (OR = 4.42, 95% CI 1.88–10.37), but not regular source of HIV care or ART adherence. Mental health mediated the relationship between stigma and ART adherence, but not poor access to care or regular source of HIV care.
Conclusions
The association of stigma with self-reported access to care and adherence suggests that efforts to improve these components of HIV care will require a better understanding of the possible effects of stigma and it′s mediators.
doi:10.1007/s11606-009-1068-8
PMCID: PMC2762503  PMID: 19653047
HIV/AIDS; HIV; stigma; care; antiretroviral

Results 1-9 (9)